DOCUMENTS R Application# il/f-5-‘/G 3 1/
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 - Ph: 910-893-7525 - Fx: 910-893-2793 - www.harnett.orglpermits
Certification of Work Performed By Owner/Contractor
(Individual Trade Application)
Owner(s)of Structure: 44246-4-0\ Phone: '/ 11 f� 7 3--cC 3�
Owner(s) Mailing Address:
Land Owner Name(s): q Phone:
Construction or Site Address: 7 7 l LA Fel Y"
PIN# Parcel#
Job Cost: Description of Work to be done
Mechanical: New Unit With Ductwork New Unit Without Ductwork Gas Piping •l er
Electrical*: 200 Amp_<200 Amp Service Change_ Serv' : -con - - l •th:i _
* For Progress Energy customers we need the premis: num.,- •_ocir
Plumbing: Water/Sewer Tap Number of Baths Wate eater
Specific Directions to Job from Lillington: rrOS2
yok/
Subdivision: Lot#:
I D,914 DG2.- 6-04 provide the // 4',/_C. -labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is , which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code and all
other applicable State and local laws, ordinances and regulations.
/-/v/9--C f/ cf,gL /$
Contractor's Company Name Telephone
et-R.
Address Email Address
ZZO 3�`
:::::::owner
/Contractor Signature: ! Date: /G'7ri/
By signing this application you affirm that you have obtained per ssion from the above listed license holder to
purchase permits on their behalf. If doing the work as owner you understand that you cannot rent, lease or sell
the listed property for 12 months after completion of the listed work.
*Company name, address, & phone must match information on license